BLOOD PRESSURE IN HEALTH AND DISEASE.

BY RALSTON LATTIMORE, M.D., SAVANNAH.

The first man to perfect a sphygmomanometer for clinical use was Prof. V. Bosch, of Vienna, in 1876.

The inaccuracy of palpating the pulse can readily be appreciated. It is about as inaccurate as trying to judge the presence of height of fever by touch and without a clinical thermometer. The spygmomanometers of most recent construction and the ones most frequently used are the Riva Rocci, Stanton's blood pressure indicator and Janeway's sphygmomanometer. The former is made in Italy and can only be obtained in the United States by importation. The Stanton and Janeway's instruments are popular and accurate enough for practical purposes. Personally I have used the Stanton indicator and have found it most satisfactory. The blood pressure in health fluctuates more than the temperature under normal condition, but has distinct upper and lower limits. establish a working basis I believe with the use of 8 C. C. cuff with systolic pressure in healthy male to be 150 M.M., as the upper limit. In females allow about 10 M.M. The diastolic pressure about 25 to 40 M.M. less. The above holds good during mental and physical rest. Excitement of any kind, especially mental, increases blood pressure. Tobacco has a marked effect, due to stimulation of both central and peripheral vaso-constrictor centers. Alcohol, contrary to the usual belief, does. not stimulate blood pressure; in fact, the pressure falls from a weakening of the vaso-constrictor centers. Healthy adults will show a pressure with the 8 C. C.

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cuff 105 to 140 systolic pressure. After middle life 140 *to 150; in children, 95 to 115. I regard with suspicion any pressure in a young person above 150 M.M.; after middle life, 175 M.M. Pathological changes effect systolic pressure more than diastolic. So much for the normal pressure; now we advance to the pathological expression of blood pressure. The readings in high pressure cases frequently range from 210 to 230 and sometimes higher, occasionally as high as 260 to 310. Hensen states the lowest systolic blood pressure at which a continuation of the circulation is possible at 75 M.M., cuff 5 C.C. The lowest diastolic pressure is hard to determine. Bright, in 1836, first noticed the combination of an hypertrophied left ventricle and kidney trouble with clinical symptoms which bear his name. Of Bright's original cases a large number died of apoplexy, and cerebral hemorrhage as a termination has been well established; though one must not consider the height of blood pressure an index of the probability of an apoplectic seizure except in a general way. Chronic interstitial nephritis, the contracted kidney of the Germans and the small granular kidney of the English writers is essentially a disease of the kidney, heart and arteries combined. High pressure is a constant feature and is usually higher than in any other disease. A systolic pressure of 220 to 250 M.M. is not uncommon. In this class the usefulness of the phygmomanometer is very marked, for in these cases, as we remember, the changes in urine are very inconstant. Albumin and casts are frequently absent and at times the quantity and specific gravity of the urine are normal. With the repeated systolic pressure of over 200 M.M. the diagnosis is almost sure. To predicate from the height of the blood pressure the expectancy of life is impossible. A gradual increase in blood pressure that resists treatment is a bad sign. In

nervous diseases of the heart Janeway says: "I have never seen a case of paroxysmal tachycardia but with a normal or subnormal pressure between the attacks and during attacks observations have been made but have not shown hypotension." The diagnosis of true and angina pectoris at times baffles us. Here the blood pressure indicator is of great service. A feeling of distress or pressure about the sternum, which is brought on especially after exertion with the constant pressure of about 210 M.M., irrespective of other troubles, is due to organic disease, although otherwise we may be unable to work out our definite physical signs. Where the pain is atypical and there is a reasonable question about it being gastric or reflex, and where exercise can be indulged in without distress, and the blood pressure is normal, the probability is that the symptoms are not associated with cardio-vascular disease and the outlook is good. Low blood pressure or hypotension almost invariably accompany typhoid fever and increases with the development of the toxemia. A slow progressive fall indicates increasing weakness of the vasomotor centers and impending collapse. It calls for stimulant medication. With hemorrhage we have a distinct fall in blood pressure, while in perforation with an accompanying peritonitis as in perintonitis from other causes, we have a well marked hypotension. Here the blood pressure indicator is of special value in making a differential diagnosis. Necessarily one must have the record of the previous blood pressure. The cold baths have a distinct effect on blood pressure as they do on temperature and pulse; when they act favorably there is a considerable rise of blood pressure. Cook and Briggs have found strychnine and digitaline to be most powerful drugs for combating cardio-vascular collapse. They give as much as a tenth of a grain if the case be urgent; digitaline acts more

quickly. Caffeine and camphor also cause considerable rise. Alcohol, contrary to the usual accepted opinion, in animals and normal men is without influence on blood pressure and the force of the heart, but it certainly acts as a food and has a good effect on the blood distribution,. but it must not be relied on singly to fight cardiac and vasomotor collapse.

In pneumonia there is no constant effect on blood pressure as in typhoid fever. Gilbert found, in favorable cases, the tension never increased materially, while in fatal cases a rapid fall to 80 or less occurred. A rising pressure with a fall of pulse indicates a favorable termination. The stimulant measure holds good as in typhoid fever. In diphtheria, compartively few clinical studies of blood pressure have been made. In Freidman's series of fifteen cases, a marked hypotension came on during the first week, only two cases recovered. Hypotension is of great importance in tuberculosis, appearing even in the incipient stage. Syphilis in the early stage is marked by hypotension. Cachectic conditions, which are due to impaired nutrition, are in a majority of cases associated with hypotension. The treatment of cardio vascular diseases has for its main object the improvement of the capillary circulation, so that it may be adequate to the demands of the tissue. The heart may be equal to the demand during rest, but not forced exertion. Therefore the essential part of treatment is a complete regulation of the patient's life. Diet, baths, and massage help. Profuse sweating will reduce blood pressure. Nitroglycerine, sodium nitrate and spirits ætheris M nitrosi produce a fall in blood, the latter very slowly. Iodide of pot. as a vasodilator is the subject of much dispute. It certainly has no immediate effect, but often relieves chronic symptoms. I am very much indebted to Dr. Theodore Janeway, of New York, for much of the above

information, and trust that this imperfect paper will stimulate other members of this Association to work along this line, for I regard it an important subject and one that will lead to valuable results.

DISCUSSION ON THE PAPER OF DR. LATTIMORE.

Dr. St. Joseph B. Graham, of Savannah: The original Bright's disease, so-called, was not an affection primarily of the kidneys, but one of arteriosclerosis, and Bright's disease may be considered as a general disease of the system.

With regard to the sphygmomanometer, the instrument that has been exhibited by Dr. Lattimore is defective in that it should have a vacuum in the top of it.